Chapter 09: A Pain Clinic for MD Anderson

Chapter 09: A Pain Clinic for MD Anderson

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Description

Dr. Hill begins this chapter by explaining why he left the Directorship of the Ambulatory Care Clinics (Mays Clinic) specifically to start a true Pain Clinic with a multidisciplinary team of practitioners, including a therapist who worked with relaxation (inspired by the model of Dr. John Bonica). Throughout this discussion he mixes observations about administration, clinical practice and research to give a portrait of how he began to explore effective use of opioids, culminating in his realization that cultural/societal beliefs prevented other physicians from aggressively treating pain with opioid drugs.

Identifier

HillCS_02_20120217_C09

Publication Date

2-17-2012

City

Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - Building the Institution; The Researcher; The Clinician; The Administrator; Building/Transforming the Institution; Multi-disciplinary Approaches; MD Anderson History; Understanding Cancer, the History of Science, Cancer Research; The History of Health Care, Patient Care

Transcript

Tacey Ann Rosolowski, PhD:

At this time, in the late ‘70s, in the early ‘80s, when you were seeing this need and others were seeing the need, how did you go about addressing this, and what led up to you establishing the pain clinic at MD Anderson in a formal way?

C. Stratton Hill, MD:

Well, when I asked to be relieved of the administrative duties, I did that with the express purpose of starting a formal pain clinic, and since I was running the clinic, I knew how to set up—there were no—they would see patients once.

Tacey Ann Rosolowski, PhD:

At the pain clinic?

C. Stratton Hill, MD:

Through the pain clinic the way it was run and that was it, and no return appointments or anything like that. It was kind of an orientation. You’re going to have a little pain or a lot of pain. You’ve got to kind of adjust to the pain, and then we had people who were giving them some instructions in relaxation and things like that but no real formal thing that was set up where you come back and follow up and set up a program. I set that all up, and then it was just actually empirical. When I saw that— And another important part of what happened during that time I was running the clinic, I was still keeping up with the medical literature and so forth, and of course, we had been working in endocrinology with a guy over at Baylor by the name of Roger Guillemin. Don’t ask me how to spell Guillemin, but it’s French. He subsequently got the Nobel Prize, he and a couple other physicians, for the discovery of the hypothalamic hormones. We were interested in the hypothalamic hormones because we thought that might be a good way to treat thyroid cancer, with radioactive iodine. If we could stimulate the cancer cells to take up more radioactive iodine, that would kill more cancer cells. So I’d started working in the brain peptides before I took that administrative job. Then about that same time, the binding sites for naturally occurring opioids were discovered, the endorphins and enkephalins, and that created quite a bit of excitement. So that came along, and that kind of encouraged me to continue looking at if there were binding sites, there must be a natural ligand that will hook on to that binding site. That’s when they discovered the enkephalins and the endorphins and so forth. I thought that was a great avenue to explore because it would maybe obviate all of the adverse problems that you had with the use of opioids. So that was in the back of my mind all along. And so take that with my experience at the beginning of seeing patients and having them come back and giving them medication that wasn’t doing them any good and realizing that, well, let me give them a little bit more, and that’s what I did. And then I got to looking at, well, why won’t other doctors do this? And that’s when I began to look at the things that I thought would be barriers to the use of opioids, because, in our case, we were dealing with people who had significant pain. We also had another guy that was working there with us that was a—I called him a defrocked Catholic priest, but I don’t think he was defrocked. I think he just gave it up. He was a psychologist and he liked to— He was toying with hypnosis. We also had a guy in physical medicine who was using the TENS unit, which is sort of the American version of acupuncture. It’s a—TENS stands for transcutaneous electrical nerve stimulation, T-E-N-S, and so we had a guy that was interested in that. So I pulled all those people together.

Tacey Ann Rosolowski, PhD:

Do you remember the name of the man who left the Catholic priesthood and then the name of the man who did the TENS unit?

C. Stratton Hill, MD:

I think the guy— His name was Villarreal, but I can’t remember the name of the priest that was a psychologist who was—he was just more of a—I suppose you’d have to call him a behavioral modification person. He was just going, “Sorry, you’re going to have to live with it,” because that’s about all they could do. Anyway, we got all those, and we had a physical therapist and an occupational therapist that was interested in doing relaxation. So I got all of those people together, and we would have them see each one of those to see if there was some kind of a way that they could add to the person’s comprehensive problem, because it is a complex experience and a negative experience.

Tacey Ann Rosolowski, PhD:

Can I ask you—because I’m just really struck as you’re talking about these individuals that you brought together in this team approach—I mean—this is basically the kind of approach that we think about with treating pain now. Was that unusual to be looking at the problem from so many different directions at that time?

C. Stratton Hill, MD:

Well, the granddaddy of all pain in the world is John Bonica. He died several years ago, but he is the one who organized the International Association for the Study of Pain. He was quite a character. I had him on that 1984 program, and I was able to get all those people on my program because of Ray Houde, in New York, who knew all these people. So I had him. John Bonica was one of the first ones to put all this stuff together, and he had a guy that was a psychologist that was a major behaviorist. His name was Wilbert Fordyce, and that was a very strong part of their program at the University of Washington in Seattle. So they were the ones that were really beginning to put together the multidisciplinary approach. And they had a guy named John Loeser, L-O-E-S-E-R, who was a neurosurgeon out there. He’s still out there. Bonica died. Fordyce is dead. They were ones— But this was not confined just to cancer pain. This was more or less pain in general. They approached— we sort of came into it with— We’d taken all comers. After they’d gotten into more of the behavioral stuff and the multidisciplinary approach, they screened their patients. You had to really qualify for their pain clinic because their concept was that there were certain people—it’s sort of like hypnosis. You’d say, “Well, this person, you can’t hypnotize this person.” They’re just not “constitutionally” fit to be hypnotized, and so they would say, “It won’t work in you, so you can’t come.” They were the ones that were really starting the multidisciplinary approach, the people at the University of Washington, and they had a lot of good people up there.

Tacey Ann Rosolowski, PhD:

What was the reaction when you began to put together this multidisciplinary team at MD Anderson?

C. Stratton Hill, MD:

Well, most of the reaction was that the doctors that were taking care of those patients were happy to get rid of them because they were probably not coming back for anymore treatment of their condition. But they had the pain, and so they were very happy to have somebody treating the pain, and particularly when we started using larger doses. That was one of the things that I took a lot of heat from. I was making everybody a drug addict, and they even said that I was giving them industrial size doses of narcotics. But you’ll see, if you look at that My Word Against Theirs, I have five patients on there that describe their condition, and by implication, you can tell that whoever was prescribing or having to follow our recommendations, sometimes they didn’t do it. One woman in particular— Because we would tell the patient what we were going to prescribe and how they could ask for medication, and we were breaking down the barriers of every four hours and— Let’s see, what was that movie? They shot it right over here on Locke Lane. Who was in that movie? I’ve forgotten the name of it. [Terms of Endearment] Shirley MacLaine was in it, and her daughter had cancer, I believe, and she goes out and asks the nurse, and the nurse says, “Not time yet,” and she just really lets that nurse have it. “My daughter has pain. You better bring it.” And I ran into that a lot. I can remember one time I said to the nurse “Go get her a dose”—or whoever it was—“a dose right now because she’s in pain,” or he’s in pain. And she went, and she said, “We don’t have any on the floor.” I said, “Well, get some.” And so she had to go get it, but it was kind of like a triumph. “We don’t have any.”

Tacey Ann Rosolowski, PhD:

Why did she react that way?

C. Stratton Hill, MD:

You tell me. That’s the cultural part that I’m talking about. These drugs have a bad name, and that’s what I said on 60 Minutes that you’ll see.

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Chapter 09: A Pain Clinic for MD Anderson

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